A 70-year-old client in a nursing home is found wandering in the hall and has a new onset confusion. Which action should the registered nurse implement ́ first?
Notify the client's family to come visit client
Instruct the client return to their room
Ask the unlicensed assistive personnel (UAP) to push fluids
Assess the client's lung fields and temperature
The Correct Answer is D
A. Notifying the client's family may be appropriate after assessing the client and identifying the cause of the confusion. However, it is not the first action, as the priority is to determine if the confusion is due to a medical condition requiring immediate attention.
B. Instructing the client to return to their room addresses the wandering behavior but does not address the underlying cause of the new onset confusion. Without further assessment, this action may delay necessary interventions.
C. Asking the UAP to push fluids assumes that dehydration is the cause of the confusion without evidence. While encouraging hydration may be beneficial later, it is essential first to assess for other potential causes, such as infection or hypoxia.
D. Assessing the client's lung fields and temperature is the first priority because new onset confusion in an older adult is often a symptom of an underlying medical issue, such as infection (e.g., pneumonia or urinary tract infection) or hypoxia. Early assessment helps identify the cause and guide appropriate interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Obtaining an arterial blood gas and ordering a chest x-ray may be necessary to evaluate the client further, but the nurse must first assess the client to determine the presence of clinical signs of fat embolism syndrome (FES), such as respiratory distress or neurological changes.
B. Keeping the client on strict bed rest may help reduce the risk of further complications, but it is not the first priority. Immediate assessment of the client’s condition is necessary to identify signs of fat embolism syndrome.
C. Assessing the client for dyspnea and altered mental status is the first priority because these symptoms are early indicators of fat embolism syndrome. Early recognition and intervention are critical in preventing further complications.
D. Contacting the healthcare provider for a ventilation and perfusion scan may be appropriate after assessing the client, but it is not the first action. Immediate assessment is essential to determine the urgency of the situation.
Correct Answer is B
Explanation
A. Atropine is used to treat bradycardia and is not indicated for pulmonary embolism. It would not be the first choice in managing this condition.
B. Heparin is an anticoagulant that helps prevent further clot formation in the case of a pulmonary embolism. It is typically administered to stabilize the patient and reduce the risk of further embolic events.
C. Dexamethasone is a corticosteroid used to treat inflammation and is not typically used to treat pulmonary embolism. It is not the first-line treatment for this condition.
D. Furosemide is a diuretic used to manage fluid retention and is not directly indicated for pulmonary embolism. It may be used in cases of heart failure or pulmonary edema, but it is not the primary treatment for a pulmonary embolism.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.